A brace is a dental , apparatus with the jaws - and malocclusions to be corrected. In principle, the treatment can be carried out by any dentist. Specialist dentists for orthodontics have, however, specialized in this through an additional three to four year further training. In orthodontic therapy, different forms of treatment and treatment aids are used, which are colloquially referred to as "braces" or "braces".
Edward H. Angle systematized orthodontic treatment between 1890 and 1920 and laid the foundations for the fixed brackets that are still in use today . During this time, Walther H. Coffin's first removable stretching device was made, made of rubber and piano wire. Georg B. Crozat developed the first system of removable appliances from around 1920 using suitable retaining clips . These were made from wires of various thicknesses.
With the advent of plastic materials, Charles F. Nord in Holland developed the active plates as an inexpensive and low-risk treatment agent. They were diversified by Arthur Martin Schwarz and his staff. In addition to spring elements, screw elements were also developed that patients can adjust themselves according to instructions.
Vigo Andresen and Karl Häupl discovered the role of the mouth muscles in the development and healing of deformities a decade before. They laid the foundations of functional orthodontics (FKO) and developed the activator as a treatment device for both jaws. For the treatment of children, activators and active plates were particularly popular in Europe. Until the 1980s, they were the predominant treatments there.
After the Second World War , various more delicate devices were developed from the then bulky activator , such as: B. the Bionator according to Balters, the elastic open activator (EOA) according to Georg Klammt or the resilient denture former according to Bimler (Wiesbaden). The Kinetor according to Stockfisch, designed as a universal device, also contained elastic components, which, however, can be assigned to the double-plate devices. The function controllers according to Rolf Fränkel are based on a different concept . Without exerting force on the teeth, they work through the muscles of the tongue, lips and cheeks for healthy jaw development.
Colloquially, there are several derogatory terms, such as "feed fence" or "snow chains". The braces are often popularly called "rabbit clips". This designation is explained by the words "bracket" (often used by orthodontists for braces) and the word rabbit or rabbit tooth (popular parlance "Hasenzahn" = jaw misalignment in which the upper jaw protrudes over the lower jaw). However, only the devices for the treatment of angle classes II, 1 are so called. The later developed, clear aligners are also called "contact lens (s) for the teeth".
Treatment and types of therapy
The treatment is often carried out using natural growth spurts (age of most patients between 9 and 14 years; girls have their maximum growth on average two years earlier than boys). Proper treatment takes an average of 2-4 years; the duration and the forecast before the start of treatment depends on the misalignment of the teeth and jaw, the type of braces and the patient's cooperation. Therefore, the exact end of treatment can only be dated precisely in very few cases. Participation includes regular compliance with the check-up appointments, following the instructions of the orthodontist (including compliance with the wearing time, any readjustment of loose braces) and oral hygiene.
In some cases, what is known as "early action" makes sense. B. through a crossbite (one or more teeth of the upper jaw interlock within the lower dental arch ; this can be the case both laterally and in front) the growth is inhibited or misdirected, if orthodontic therapy should enable normal, harmonious growth again. Early treatment is also advisable in the case of an open bite to improve biting, and in the case of extreme lower jaw recession to improve the chewing function and to prevent accidents (incisors protruding too far are often affected by loss or breakage). An early measure is usually started between the ages of 4 and 7 and usually lasts one to one and a half years.
In the case of children, the cost of braces is fully covered by the statutory health insurance under certain conditions. There are so-called KIG guidelines (orthodontic indication groups) for determining whether the costs will be covered. The need for treatment is classified according to a specific scheme on the basis of indication groups. The orthodontist usually takes an X-ray image and models, which he can use to classify the indication. The costs are covered, for example, if there is a cleft lip and palate or an eruption disorder of teeth (except wisdom teeth), with a sagittal step of over 6 or over 9 mm, with crossbite or lack of space of over 3 mm.
People who have already reached the age of 18 will no longer be covered by the health insurance company without the necessary additional surgical therapy. But orthodontic treatment of adult patients of all ages is now an integral part of maintaining the health of teeth and jaws for life under dental care. Contrary to previous opinions, treatment is possible at any age.
In addition to "myofunctional therapy" with targeted exercises and simple aids for straightening teeth (tooth spatula, oral vestibule plates, etc.), treatment with removable devices or fixed appliances for malocclusions and teeth can also be considered.
When it comes to removable appliances, a distinction is made between active plates for the upper and lower jaw and functional orthodontic appliances (FKO appliances). Active plates, including special shapes such as B. Fan expansion plates, Y-plates, advance or return double plates, are particularly suitable for children in the mixed dentition stage. There they can create space for the teeth and also open narrowed gaps again. You can line up the new teeth and create the congruence of the dental arches. Active plates are used in the permanent set of teeth to reduce tooth movements .
FKO devices influence the growth of the jaw with the aim of a normal bite position (neutral occlusion), whereby they also normalize muscular imbalances in the mouth area that are associated with the deformity. If FKO devices are ground in accordingly, they can also allow the teeth to grow painlessly in one plane in the event of vertical anomalies (deep bite, open bite).
These removable braces are made individually on plaster models and offered in many colors and sometimes with child-friendly motifs. The children / parents are given a minimum wearing time that must be observed if the treatment is to be successful. In the course of a treatment, several devices are sometimes used, e.g. B. a removable device after a fixed brace to avoid any back movements of the teeth ( retainer ).
A device popular in holistic orthodontics is the Bionator , which focuses on the promotion of suction and force. Sometimes holistic practitioners also use Crozat devices.
Ready-made trainers such as B. the splint activator are to be classified between the myofunctional aids and the functional devices.
Correction splints (aligners) made of transparent plastic are a relatively new product. In contrast to classic braces, aligners do not have adjustable elements, but after an impression has been made and the treatment goal determined, several intermediate steps are calculated with a 3D computer graphics process and a corresponding number of transparent plastic splints are produced. These aligners are worn sequentially for 2 weeks each. There are also optimized procedures with treatment cycles made up of soft and hard splints. For treatment periods of 9 to 18 months, up to 36 splints are required. The aligners can be easily removed while eating and cleaning your teeth and are hardly visible. The pronunciation can be influenced to a greater or lesser extent at the beginning of the treatment, usually improving over time.
Types of fixed braces
- Multiband or multibracket apparatus
- Autumn hinge
- Delaire mask
In the case of fixed braces, a distinction is made between the intraoral multiband or multibracket appliance applied to the teeth and that of extraoral aids (face masks, headgear , etc.).
The materials used in the multi-bracket appliances (tooth brackets) range from stainless steel to titanium, plastic and even to the transparent ceramic bracket. The brackets are glued to the teeth after the enamel has been etched. The brackets are used to attach a wire that presses the teeth into the desired position. Metal brackets and the wire are clearly visible. By using ceramic brackets in tooth color and Teflon-coated wires, however, the appearance can be made much more inconspicuous. In any case, the pronunciation is influenced.
With the help of the fixed multi-band appliance, teeth can be straightened at any age if the jawbone is sufficient. Once inserted, the appliance can cause pain for days to weeks, and the affected person may not be able to chew without pain. There is also frequent irritation of the oral mucosa and, in some patients, an increased incidence of aphthae .
A major problem with fixed braces is the fact that the braces “must” be worn continuously for years and cannot be taken off in exceptional cases (sport, photos, appearances). This problem is often underestimated at the start of treatment or can often not be assessed objectively due to the long period of time, especially because the responsible persons (parents) who decide on the type of braces often lack their own experience with fixed braces. If you can decide between a loose and a fixed appliance due to the misalignment of the jaw, you see the primary advantage of fixed braces that the child cannot cheat when wearing them compared to the loose appliance. Aesthetic and psychological reasons are often ignored, but should not be underestimated for the patient. Even when the mouth is closed, fixed braces can often be suspected, as the lips are pushed a little forward and the entire mouth area appears larger.
Different multibracket treatment methods
There are very different multiband appliances in orthodontics. The appliances differ significantly in the design of the bracket. The structure of the bracket determines how the forces of the wire are transferred to the tooth. Modern orthodontics tries to move the teeth with as light and precisely dosed forces as possible, as this has a considerable influence on the comfort of the treatment. The so-called friction values of the brackets are an indicator of the quality of the treatment. The following treatment methods and brackets can be distinguished.
- Edge-Wise Technique : This method was developed by Edward H. Angle . The bracket consisted of a straight slot, on the side of which there are two or four binding wings. The arch wire runs through the slot between the tie wings. A so-called ligature is pulled over the binding wings and fixes the archwires in the slot. The design of the Edge-Wise Bracket enables the entire tooth, including the tooth root, to be moved in the jaw (bodily movement). Many orthodontic treatments today are carried out with the Edge-Wise or the straight-wire technique developed from it, which is more intensive in additional parts. For several years now, more and more self-ligating brackets have been used. In contrast to the classic straight-wire brackets, the archwire is not fixed by an attached rubber or metal ligature, but rather a locking technology built into the bracket holds the arch in the bracket. These self-ligating brackets often have less friction between the arch and the bracket. In addition, the orthodontist can change the arches more quickly and easily.
- Begg technique : Percy Raymond Begg developed the so-called light wire technique in the 1950s . Begg had learned the Edge-Wise technique from Angle himself, but then developed his own technique. The special thing about the Begg technique is the way the teeth are moved. First, only the tooth crowns are moved to the desired position. This requires only little force, since the tooth crowns can be moved relatively easily. Only at the end of the treatment are the roots of the tooth moved into the correct position, often faster results than with the straight-wire technique. The Begg technique is more complex for this. The practitioner must adapt each individual archwire to the patient. Not least because of this, the Begg technique does not seem to have prevailed against the straight wire method. A further development of the Begg technology has been available since the 1980s: the so-called tip-edge bracket simplifies treatment and largely eliminates the need for time-consuming bending of the wires.
- Lingual technique: With the lingual technique, the brackets are not placed on the outside of the teeth, but on the inside, i.e. the side of the tongue (lingual). In contrast to the outside of the tooth, the inside of the tooth is shaped differently in every person. Therefore, with the lingual technique, the brackets have to be made to measure for each tooth. This makes lingual braces significantly more expensive than all other braces. In the meantime, however, standardized lingual brackets are also on the market, which do not require customization. Lingual braces have the great advantage that they are almost invisible. However, the lingual brace can interfere with pronunciation. In addition, the archwires must be made individually and are difficult for the orthodontist to use.
Mechanism of action of the multibracket appliance
The basic principle of the multibracket appliance is that a bracket is attached to each tooth to be moved. The bracket is aligned with the tooth. So if the tooth is tilted or rotated, this also applies to the bracket. A thin metal wire, the so-called arch wire or “arch” for short, is attached to each bracket and necessarily deformed in the process. The elastic recovery tendency of the arch now exerts a force on the teeth, which leads to the tissue in the periodontal gap being compressed in places (pressure zone) and stretched in the opposite places (tension zone). This stimulates remodeling processes in which osteoclasts break down bone in the pressure zone and osteoblasts build bone in the tension zone. When the first, usually very thin, sheet has largely recovered, a thicker sheet is used. In the course of a treatment there are several "bow changes".
Installation of fixed equipment
In the event that metal cuffs ("straps") are necessary for therapy (for example to anchor additional parts primarily using straight-wire technology, such as headgear or quad-helix, to the teeth), a few days before the actual installation the respective teeth rubber rings / separating rings pressed. In this way, the teeth are pushed apart a little, which simplifies their harnessing.
professional teeth cleaning:
thorough cleaning of teeth with special brushes and polishing paste
The actual bracket is welded to the strap to be installed. First, the right band is selected by trial and error, so that there are no unhygienic spaces between the teeth. This band is filled with cement, pressed onto the tooth and brought into its final position with special instruments, where it then remains for the entire duration of the treatment.
Etching or roughening the tooth surface: In
order for the bracket adhesive to adhere, the tooth surface is briefly roughened with a special gel.
Rinsing and bonding the brackets:
The etching gel is removed with a water spray and the roughened tooth surface is dried. The brackets are provided with dental superglue ( cyanoacrylate adhesives ) on the roughened back .
Positioning the brackets:
The bracket is placed on the tooth with special orthodontic positioning instruments. This must be done very precisely so that the effect of the bow can be optimally used later and no treatment errors occur. As long as the adhesive has not yet hardened (which is accelerated with light-curing adhesives with a UV lamp), the position of the brackets can still be changed slightly.
Insertion of the archwire:
After inserting the brackets and ligaments, the first very elastic archwire (the actual clasp or the actual instrument that exerts the forces for tooth regulation) is inserted into the tubes on the ligaments and into the brackets. To prevent it from slipping, small rubber rings (alastics) are placed around each bracket. For later control appointments, stronger wire arches are used. T. are thicker and z. T. have a different cross-section. They exert stronger forces on the teeth, but do not necessarily cause greater pain in the patient, since the entire jaw apparatus is already used to the pressure and the teeth have already been moved.
The first few days after installation:
While the lengthy procedure of insertion (approx. 60 to 180 minutes) is usually not painful, in the first few days afterwards v. a. pain when chewing, depending on physical sensitivity and eating habits. The unfamiliar foreign bodies in the mouth can also cause sores on the lips and cheeks. Against this it often helps to cover the disturbing foreign body edges with special wax. If the pain persists after a few days, the orthodontist should be visited again so that the braces are loosened up a little. Not to be underestimated is the psychological stress of some patients due to foreign bodies built into their mouths over the years. It is therefore advisable to weigh up removable braces with their possibilities and limits in advance and, if necessary, obtain a different opinion.
Treatment errors in follow-up care
A classic treatment error in aftercare is z. B. after removing a dental bracket, leaving fixation residues on the teeth. Fixations that are not ground away become foci of bacteria and promote irritation of the gums such as bleeding gums or inflammation of the gums .
Every person with statutory health insurance is entitled to orthodontic treatment within the framework of statutory health insurance, which must be offered free of charge, with the exception of the deductible. It must not be made dependent on private additional payments. At the same time, after having been informed and agreed with his or her orthodontist or dentist, the patient must be able to decide on treatment that goes beyond statutory health insurance. A newly developed sample form can serve as a contractual basis for additional or alternative services that are requested by the patient. All planned additional treatment measures and associated costs as well as the patient's own contribution resulting from this are shown on the form.
In Austria, the costs for braces in the case of "significant" tooth or jaw misalignments (misalignment according to the international IOTN classification in the two highest levels 4 or 5) have been fully covered by health insurance since July 2015. There are usually removable braces for children up to 10 years of age, and fixed braces for children up to 18 years of age. The previous grants for minor misalignments will not be canceled - contrary to earlier fears. The so-called free braces with complete reimbursement of costs by the Austrian health insurance company can only be offered by contract orthodontists.
Complications and risks
There is a risk of allergic reactions to the metals or rubber linings used in the braces ( latex allergy ). A anaphylaxis is the extent possible. However, allergy-related special treatments with, for example, nickel- or latex-free materials are offered.
Particularly firm braces can promote the development of caries or gingivitis due to the difficult oral hygiene as well as the risk of root shortening due to painful long-term exposure to locally excessive forces.
The brackets can be glued on incorrectly so that the tooth movements cannot be carried out correctly. Improvements or an adjustment of the regulation would be the result if the problem or the error is not recognized in time.
The wrong arch is used so that the desired effect is not achieved and the tooth movements are too strong (with possible root damage) or too weak (which leads to an extension of the duration of therapy).
state of scientific knowledge
The DIMDI ( German Institute for Medical Documentation and Information ) wrote in 2008 in its Health Technology Assessment report " Oral health after orthodontic treatment with fixed appliances ", among other things, that this form of orthodontics was " scientifically insufficiently secured "; one comes across " ... in the search for scientific evidence for the effectiveness of orthodontic measures on numerous open questions ". Above all, he complains about the lack of studies on the effects on dental and oral health. There is a gap between the practical application of orthodontics and research into its effectiveness in terms of overall oral health. The report called for research efforts to be more evidence-based treatment.
The British newspaper The Daily Telegraph reported on March 18, 2004 that braces are considered “cool” and “sexy” by young people. They would rather be viewed as a fashion accessory. It is about colored rubber bands that hold the brackets together, said a spokesman for the British Orthodontic Society.
"The boys want braces the color of their soccer team, the girls want something that goes with their weekend outfit," said one orthodontist. He has had patients who came for an orthodontic consultation and were disappointed when they didn't need braces. The spectrum of “wanting” braces ranges from one extreme to the other extreme - similar to many other therapies or devices that are established for medical therapy.
- Medical education
- Healing treatment
- Informed consent
- Occlusal splint
- Aligner Therapy
- Prummel bracket
- Cost of braces
- Treatment of adult patients ( Memento from May 31, 2009 in the Internet Archive )
- B. Kahl-Nieke: Introduction to orthodontics. Deutscher Zahnärzte Verlag, 2010, p. 236.
- Rudolf Meyer: The Tip Edge Plus Bracket. In: Swiss monthly for dentistry. Vol. 118, Ed. 8, 2008, pp. 713-722.
- B. Kahl-Nieke: Introduction to orthodontics. Deutscher Zahnärzte Verlag, 2010, p. 244.
- Orthodontic treatments: transparency for patients improved. Press release of the National Association of Statutory Health Insurance Dentists, the German Society for Dentistry, Oral and Maxillofacial Medicine, the German Society for Orthodontics and the Professional Association of German Orthodontists (BDK) from October 16, 2015, accessed on October 29, 2014.
- Free braces for children from July 2015. In: Kurier. November 20, 2014 (online date)
- List of contract orthodontists in Austria.
- M. Mavragani, A. Vergari, NJ Selliseth, OE Bøe, PL Wisth: A radiographic comparison of apical root resorption after orthodontic treatment with a standard edgewise and a straight-wire edgewise technique. University of Bergen , December 22, 2000.
- J. Artun, I. Smale, F. Behbehani, D. Doppel, M. Van't Hof, AM Kuijpers-Jagtman: Apical root resorption six and 12 months after initiation of fixed orthodontic appliance therapy. University of Kuwait, 11.2005.
- Wilhelm Frank, Karin Pfaller, Brigitte Konta: Oral health after orthodontic treatment with fixed appliances. (PDF; 381 kB) HTA study 2008, report no. DAHTA066. DIMDI , 2008, accessed November 22, 2012 .
- DIMDI: New HTA report sees orthodontics as scientifically inadequate to date ( memento of February 27, 2009 in the Internet Archive ), April 22, 2008.
- D. Kloos: "Trendy with rods": Nothing works without braces !? ( Memento from April 12, 2013 in the web archive archive.today ) In: ZBay online. 1/2, 1999.