So I got asked “What are the Five Stages of Orthodontics?” and was a bit surprised because it wasn’t a phrase I’d instinctively use, but I figured someone had been spending a bit of time on the internet looking into the stages of braces treatment.
When I studied orthodontics, we considered orthodontic treatment to take place in three main stages:
- Levelling and alignment
- Translation
- Finishing
(I’ll explain the terms a bit later on)
But… five?
Though on reflection, there are a lot more phases but some of them are so universal to any form of medical or surgical treatment that I wouldn’t have thought of them as stages of orthodontics specifically and the others are so consequential to those three phases that I didn’t credit them with their own number. But here goes (Ta-Dah!):
The Five Stages of Orthodontic Treatment
- Bonding
- Levelling and alignment
- Translation
- Finishing
- Debonding
But really, you need to add “Retention” as the sixth stage. Of five stages. So why stop at five, or six? So you have to think about what happens during orthodontic treatment.
But that’s not the whole story, so here’s my Swords Ortho Stages of Orthodontic Treatment:
- Presenting Complaint or Condition
The patient tells me what they don’t like about their teeth, or their dentist tells me what they have found to be wrong that might need orthodontic treatment to put it right. This is very much an act of listening to the patient
- History of the complaint
We look into any story behind the problem, causative factors, previous treatments and experiences. This can be particularly important in cases of early tooth loss, trauma, gum disease
- Medical History, Dental History, Family Factors
These observations can give me some context as to what might be going on, and also may modify some of my actions on what we can do for the patient so it’s best to know as early as possible. Some orthodontic problems run in families (like missing teeth or certain unusual jaw sizes/relations)
- Examination
Using a few basic instruments like a ruler, a small mirror and a pointer, I’ll look at the patient in a systematic process, beginning with the relationship of the front teeth (assessing compared to British Standards Institute 4492), progressing on to the relationship of the jaws to each other and the rest of the face, and then on to the alignment and positions of the teeth, and how they contact on closing or moving left and right. Then I’ll carry out a simple check for mouth cancer and record the teeth present and other observations. There will be an examination of the jaw joints and health of the gums as well.
- Special Investigations
These are additional procedures that help me assess the patient beyond what I can see with my own eyes and basic instruments. The most routine form of special investigation in dentistry is an X-ray picture. That allows me to see unerupted teeth, the state of the development of the teeth, the absence of teeth that haven’t developed, or the presence of extra teeth, and if the teeth have tooth decay that’s not obvious. Special orthodontic X-ray pictures called Lateral Cephalogram are often used to measure the jaw relation and how the teeth are inclined (tipped forward or backward). Because Swords Orthodontics is a specialist orthodontic practice that is geared up for ortho treatment we have the special X-ray equipment for these views. This surprises some patients, as they think I’ll need to send them off to a hospital to get them done.
As well as the investigations, we’ll get a model made of a patient’s teeth – these days this is a digital model made using a scan directly of the teeth – and a set of photographs of the teeth.
The investigations and records collecting usually happens on the second visit and my team take care of the procedures, under the direction of the orthodontists.
- Diagnosis and Treatment Planning
This is why a patient goes to an orthodontist. An orthodontist goes through the aspects of the problem and works out a solution to them, and considers the pros and cons of the different actions that we (the patient and the orthodontist) would take along the course of treatment and the ways we minimise the side effects of the different actions (there’s usually some because as every Star Trek fan knows, ye cannae change the laws of physics) to get the best result. I usually do this between the second and third visit.
- Treatment Discussion and Informed Consent
This is usually a visit in itself, where the orthodontist personally talks to the patient (or parent) about the problems that have turned up on the examination and the special investigations.
It may well be that there are problems that the patient wasn’t aware of. That baby tooth that didn’t fall out yet? Well maybe the adult tooth that’s meant to replace it never formed. Or maybe it did form but went off course and is now sitting on the wrong side of the jaw or has damaged a tooth next door. These sorts of conversations are always best done with big photographs of the teeth and the X-ray pictures on the monitor so I can point out stuff. Most people will never have seen their own teeth in the way that a dental photograph shows them.
After showing the problems, it’s important to mention what would happen in the absence of any treatment. By and large with teeth, most problems stay the same or get worse when not treated, but it’s important to have a dentist go over the details for an individual’s case. In some orthodontic problems, there might be things a patient would have to do to get the best outcomes if they don’t want treatment – for example, wearing a mouthguard for sports if they have a big overjet (their upper teeth stick out).
Then we would go through the treatment plan. There may be options for this, and our job is to present them to you and give you the information to make a choice. Then we’d go through the pros and cons and potential problems that might arise from orthodontic treatment and what they would mean for the patient and the responsibilities the patient has for their part in treatment.
Unsurprisingly, this is just a variation on "do what the orthodontist tells you", usually:
- “keep your teeth clean” and
- “be careful about what you eat” and
- “put these elastic bands on your braces the way I show you” and
- “wear your braces as instructed” and
- “tell us if you notice a problem”
and you can’t go too far wrong
I’ll usually show pictures, x-rays, models of teeth or braces or videos to explain what’s going on or what I’m planning to do.
In Swords Orthodontics this is usually the third visit. At the end of this visit you should have a good idea of what’s involved in treatment and be able to make a decision to go ahead or not.
- Review or Phase 1 treatment
This doesn’t happen for all patients, but in our younger ones, they may not be ready for treatment so we have to wait and have the occasional review of the teeth to see that they are developing as expected. For other patients, we have an early phase of treatment that doesn’t fix all the problems but either intercepts an early developing problem (like a tooth erupting off course) or a narrow top jaw, or a tooth in crossbite, or an overjet with a high risk of traumatic dental injury or early loss of baby teeth before the adult teeth are due to replace them.
Quite often a “Phase 1 Treatment” involves a brace called a Twin Block to correct the relationship of the upper and lower teeth when the upper teeth are too far forward compared to the lower ones (or the lower ones are too far back compared to the upper ones)
- Bonding
This is the trade term for “sticking fixed braces on your teeth”.
- Levelling and Aligning
This is the early stage of fixed braces treatment. When the braces are attached to your teeth, an individual attachment is on each tooth that we want to be part of the brace system. These are usually specific for each tooth – there’s an upper right canine attachment on the upper right canine for instance – and then they are connected by a bendy wire. The wire is distorted by being placed in the teeth that aren’t aligned and it tries to recover its shape…which is the shape of an ideal dental arch. As it returns to the shape of an ideal arch, it takes the teeth with it. At the same time, it tries to level out the teeth which are usually at different heights.
As the teeth get straighter and more level, the wires that connect them can be stronger. That’s because it’s the distortion of the wire that generates the force to align the teeth and the better aligned they are, the less distorted the wire is and the less force a lighter wire will generate. As the wires get bigger and stronger the more force that small bends and distortions in the wire can generate.
Eventually you get to steel wires which can be permanently bent into a shape that suits the tooth movements. This stage can last a few months. It would be rare to take longer than 12 months, but it’s not impossible.
- Translation
At the end of the levelling and alignment phase, the teeth should be pretty straight but may not be in the right place. Moving a tooth from one place to the other, while keeping it at the same orientation (tip/inclination/rotation etc) is called translation and it needs a “strong” wire and low friction. Steel wires are usually the choice for this. Teeth may have to move an entire tooth width or more to get to an ideal position.
This phase might take as much as a year, maybe longer.
- Finishing
This is the final months of fixed brace treatment. Usually involving little bends in the wires, or late-treatment bracket repositions. The aim here is to get the teeth biting together well at the back and the contact points for each tooth nicely lined up with the tooth next door. The team here at Swords Orthodontics are used to hearing me call out the notes “first order bend lower right two-one” and similar dental words.
- Debonding
This sounds like something drastic but it’s just the word we have for removing the braces from the teeth. It’s the opposite of “bonding”. This is the last day of braces, basically. So we all have to be happy with the result we’ve got. Just because an appointment is made to take the braces off, we won’t do it if you’re not happy about some aspect of the finish and we’ll work at whatever needs done until you give us the nod. We check the alignment of the teeth (how straight they are), the basic occlusion (how they bite together), the dynamic occlusion (which teeth touch and which teeth separate when the teeth are moving from side to side but in contact – as if they were chewing food). If everything is looking good, then we have the dental equivalent of “the man from Del Monte says yes” and we take the braces off.
How do we take the braces off the teeth?
For fixed braces, the brackets come off the teeth one at a time with a simple click using an instrument uniquely made for this procedure. We don’t use it for anything else. The whole procedure takes about 2 minutes or less for about 2 dozen teeth. Then we remove the remaining tooth glue from the teeth. This is done with a power instrument because even though the tooth glue is a very thin layer, it’s very hard because it’s made of microscopic glass particles.
Or if the treatment was done with aligners, then the little attachments come off the teeth. They’re made of the same stuff as the tooth glue, so we’d use a power instrument for this as well.
Once the teeth are back to being smooth, the first thing 99.999999% of patients do is say “oh, that’s really weird”.
Next thing is to take a scan of the teeth. In the old days, we used to take a moulding of the teeth, but patients almost all prefer the simpler procedure of a digital scan of the teeth. This gets used to make a digital model of the teeth, then we print out a 3D model of the patient’s teeth and use that to make their retainers.
We take a set of photographs when the braces come off as well, so we have a record of what the teeth looked like at the end of treatment. This is useful for tracking any relapse or growth changes in the teeth in the future.
- Retention
We fit retainers very shortly after the braces come off. For our aligner patients, they can usually wear the last aligner as a temporary retainer while we make up the retainers, but for the fixed braces patients we like to get retainers sorted out within 24 hours, often on the same working day – if we take the braces off in the morning, we’ll aim to get the retainers fitted that afternoon. If we take the braces off in the afternoon, then it’s usually the next day when we fit the retainers. We don’t usually take braces off on a Friday afternoon or Saturday as I don’t want a patient waiting all weekend without a retainer.
If a patient needs a bonded retainer, then the process is a bit more complicated and we’ll arrange other appointments as needs be.
I’m clear to all the patients, the retention phase doesn’t end for as long as you want to keep the result.
- Additional associated treatment
This isn’t true for all our patients, but some of them have more dental treatment due once the orthodontics is complete. I advise all patients to have a review with their general dentist after treatment as this will be the first time that the dentist can examine the teeth without the braces in the way.
For some other patients though, the orthodontics was one part of their overall treatment. This could be because they had unusually shaped teeth that need reshaped to a more natural-looking shape or it could be that a tooth was missing and we had to reposition a tooth to substitute for it and it’ll need some sort of reshaping to look like the tooth it’s simulating. Sometimes a tooth is missing and the dentist will need to arrange an artificial tooth (a prosthetic tooth) to fill the space.
Our retainers fit the teeth so exactly, I advise patients that if they do anything that changes the shape of a tooth they will need a new retainer made immediately after, so it’s important to organise their appointments in a way that coordinates between the patient, their own dentist, and Swords Orthodontics.
- Review
We don’t just finish the relationship because the braces came off. Swords Orthodontics will review all the retainer patients for about a year after treatment. Some of the patients might need a longer review if I’m waiting for their facial development to slow down to adult levels before doing more treatment or before deciding that we can sign off on a final appointment.
I’m always happy to see an old patient come back out of the blue to get a new retainer. It’s fascinating to see them, say, ten years on and they studied something unusual in college or got a job I need to have explained to me, or moved to a different country or started a family or whatever. I love to find out how well the teeth held their positions (the answer is usually that they held well, because these are the kind of patients that did the things you asked them to do and wore their retainers after treatment).
…and the other stage of orthodontic treatment? It hasn’t happened yet, but we’re getting closer as I get older and practice longer, but sooner or later I’m going to be treating the children of a former patient that was a child when I treated them.