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Types of braces: Extractions in orthodontics

Are they necessary?

Extractions as part of orthodontic treatment are required somewhat less frequently than in the past on account of advances in orthodontic techniques. There has been widespread adoption of braces which take advantage of the growth of the patient's jaw to correct the bite, possibly also creating small amounts of additional space in the dental arch. These braces, known as functional appliances, are routinely used now by most orthodontists and can often avoid the need for extractions. Other advances have likewise reduced the proportion of cases where extrctions are recommended.

It is sometimes asserted that these techniques are appropriate in all cases and that narrow jaws can always be widened to bring overcrowded teeth into line without extractions. But the evidence is that this approach, applied uncritically, can lead to excessive prominence of the teeth greatly increasing the risk of subsequent relapse.

There is little doubt that well-planned orthodontic treatment can both improve the bite and enhance a patient's overall appearance. Every course of treatment needs to be tailored to the needs of the individual patient. For many patients, in order to get the best appearance and long-term result, extractions will still be part of the process.

In reaching a decision on extractions, a full assessment of the patient's face, teeth and state of development is essential. A meaningful opinion cannot be given on whether extractions will be required in the absence of such an assessment. Any offer to treat without extractions made before such an assessment should be regarded with considerable caution.

It is important that the recommendations of your orthodontist command your confidence. If you are unsure about the advice you are receiving, you should discuss your concerns with your own dentist. You might wish to seek a second opinion from another specialist, to which everyone is entitled under the terms of the NHS.

For any further information, or to arrange to speak to a representative of the BOS, call 020 7353 8680.

What will it cost?

The NHS makes some provision for orthodontic treatment but only the more severe cases are covered under current regulations - minor problems are excluded. Treatment for children is free of charge; treatment for adults is not commonly funded by the NHS, although in cases where it can be offered in a practice the standard NHS charge for complex dental treatment applies - this is currently just under £200.

Fees for private orthodontic treatment vary widely. Average fees for a complete course of treatment are probably around £2000 to £2500 but in many instances can be much higher. The fee is much affected by the complexity of the case, the locality, the facilities of the practice and the experience of the practitioner. Certain techniques such as lingual orthodontics are also much more expensive.

Prospective patients should seek further information from local practitioners. A firm quotaton will normally only be possible after the orthodontist has had a chance to assess the nature of the problem at a consultation.

How long will it take?

It is impossible to give a definite answer. Simple cases may be completed in a few months, the average case may take 18-24 months, while complex cases may take three years or more, especially if jaw surgery is involved.

Patients vary a lot as to how fast their teeth will move and this is something which cannot be predicted in advance of treatment.

On average cases needing extractions take longer than non-extraction cases.

Cases involving jaw surgery will take longer.

Your orthodontist will be able to give you an estimate of the likely timescale, but this will be very approximate.

Is it painful?

A degree of discomfort is likely to start with. You can expect some aching and tenderness in the gums as the teeth start to move, but this mostly wears off after a few days.

Fitting the brace should not be painful. For a fixed appliance the brackets are simply glued to the faces of the teeth; metal bands may also need to be cemented round the back teeth. No anaesthetic is needed.

As the biological processes get under way round the tooth roots to allow the teeth to move, you can expect some aching and the teeth will be tender to bite on. This usually settles down in a few days, although some patients do experience a degree of tenderness for a longer period. The amount of discomfort varies enormously from person to person. It may be helpful to take your normal painkillers or a day or two.

Some further discomfort may be experienced when the brace is adjusted subsequently, but this depends very much on what adjustments have been made.

I don't want to wear the metal braces

What are my options?

Ceramic brackets are relatively inconspicuous on the teeth.
Lingual braces are placed out of sight on the inner surface of the teeth.
Aligners are clear plastic splints which fit over the teeth and progressively move them to the desired position.
Each option has its advantages and disadvantages and specialist advice is essential.

Ceramic brackets

Ceramic brackets are tooth coloured or translucent. They are less conspicuous than metal brackets and therefore often favoured by adults. However they do have a number of drawbacks which need to be taken into account. The brace tends to become discoloured over the course of time by contact with foods and may become less pleasing in appearance. The brackets are more prone to breakage than metal brackets; the wires slide through the slots less freely so treatment may take longer; the brackets tend to be abrasive and may cause wear to teeth in the opposite jaw if they should make contact when biting; the brackets can sometimes be difficult to remove with a slightly higher risk of damage to the tooth surface. The brackets are also more costly than metal brackets, and with all the associated problems the overall treatment can be expected cost significantly more. Having said all this, if appearance is at a premium, ceramic brackets may still be the first choice for many patients.

Lingual appliances

These are attached to the lingual surface of the teeth, i.e. the surface towards the tongue. In this position they are virtually invisible. The technique involves special skills and needs considerable experience on the part of the orthodontist to achieve good results. Only a limited number of orthodontists offer this technique and you may need to search for a suitable practitioner who has the requisite experience. The main drawbacks are that it can cause soreness of the tongue and affect speech. Fees are always much higher than for conventional fixed braces because of the higher material costs, greater surgery time involved and the extra training needed. More information on lingual orthodontics.

Aligners

These are often known by their commercial names such as Invisalign and Clearstep. They blend modern technology with the long-standing concept of using clear flexible splints to ease teeth into line. A succession of splints is worn, each splint bringing the teeth a little closer to the desired position. The splints are effectively invisible and are therefore an attractive option from the standpoint of appearance.

Aligners can be very effective if all that is required is to align mildly irregular teeth. However there are several drawbacks. In the more severe cases, notably those where extractions are required, aligners lack the necessary control of the teeth to give consistently good results and often lead to disappointment. Likewise they are not well suited to correcting problems like prominent upper incisor teeth.

The cost is much higher than for conventional fixed braces owing to the high laboratory costs in making the aligners. In selected cases they they are very effective but their scope is limited.

Will I need retainers?

Most probably yes.

The tissues around the roots take time to adjust to the new tooth positions and there is a particular risk of relapse in the early months after the brace is removed. Even in the longer term some risk remains and the best advice is to continue retention indefinitely if at all possible.

Retainers may be removable or fixed, and there are advantages and disadvantages to both.

  • Removable retainers are usually worn full time initially, but reduced to night times only later. They are effective but obviously depend on the patient remembering to wear them. They will need occasional repair or replacement, a relatively simple task.
  • Fixed retainers are usually bonded to the back of the teeth. They are therefore in place all the time and are highly effective. A high standard of tooth cleaning in the vicinity of the retainer is essential to avoid gum problems. They do need regular inspection because if any of the bonds fails, the tooth in question may start to drift out of position. For this reason it is essential for the patient to contact the orthodontist at once if there is a breakage. Many general dentists are unhappy about repairing a fixed retainer and a visit to an orthodontist will be needed.

What can be done without wearing braces?

Orthodontics can be a lengthy process. Some patients prefer to have crowns or veneers fitted to their teeth instead in order to mask the irregularity. Whether this is feasible in any particular case needs good professional advice.

Veneers are added to the front surface of the teeth to mask the irregularity. The teeth can be reduced in size and crowns or "caps" can be fitted to give a larger change in appearance. These approaches also allow defects in the tooth surface to be hidden.

These restorative approaches offer the attraction of rapid results and may be the treatment of choice in some cases. Drawbacks that you need to be aware of are:

  • the preparation of the teeth is, to a greater or lesser extent, a destructive and irreversible process
  • the crowns or veneers cannot be expected to last indefinitely and the need for replacements over the years should be borne in mind
  • there are definite limits to the amount of irregularity which can be tackled successfully in this way. Veneers can be become excessively thick, crowns can only be reshaped by a limited extent
  • there may be adverse effects on the underlying gum tissues over the years from having the edges of the crowns or veneers close by
  • Is it painful?

Can adults be treated on the NHS?

In principle adult orthodontic treatment can be provided under the terms of the NHS provided the need for treatment is sufficient. But...

The NHS contracts held by many orthodontists do not include adult patients. In some areas there are no orthodontists at all with NHS contracts to treat adults. An enquiry to your local PCT or Health Board may be useful. Adult treatment under NHS contract incurs the standard NHS charge for complex dental treatments which is currently around £200.

For the most severe problems, notably those requiring jaw surgery, treatment for adults may be provided by the NHS through the hospital service. A referral from your dentist is needed. However hospitals do not normally accept routine orthodontic cases for treatment and in the majority of cases adult orthodontics is carried out under private contract.

How much will it cost?

There is no "going rate" for private orthodontic treatment. Costs are typically in the range £2000 to £4000.

The cost of treatment depends on several factors. Orthodontics for adults tends to be cost more than for children. The overall cost will be affected by the complexity of the case, the type of brace to be used, the experience and training of the orthodontist, the locality and the facilities of the practice etc.

To obtain a definite figure you will need to arrange a consultation with the orthodontist- this should not involve you in any commitment to proceed with treatment. The orthodontist will then be able to assess the problem, discuss the options with you and set out the costs.

A few facts about Orthodontics

  • One in three children has a significant derangement of the teeth and needs orthodontic treatment.
  • This figure is based on the Index of Orthodontic Treatment Need, the yardstick adopted by the Department of Health for use in the NHS
  • There are 36,000 dentists but only 1200 specialist orthodontists. (based on General Dental Council statistics at 31st December 2008)
  • Britain has fewer orthodontists relative to its population than almost all European countries.

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