Saba Qureshi explains the benefits and potential problems of braces and whether she believes they’re worth the effort.
It never ceases to amaze me how much orthodontic appliances, whether fixed or removable, can change a smile. We can place the teeth more or less where we want, within biological limits and of course. But keeping them there is another matter…
Once active treatment ends, the battle against relapse begins as we enter the maintenance phase, forever chasing the elusive entity that is long-term stability.
The waters are pretty muddy when it comes to retention. Rather than a professional consensus regarding the ideal maintenance regimen, through experience, trial and error, most physicians formulate what works best for them and their patients.
Most orthodontic patients will have a combination of fixed and removable braces.
While removable braces are fairly easy (as long as they are worn), fixed braces can be somewhat problematic.
Fixed retainers were first introduced in the 1970s, usually consisting of a round or rectangular blue elgiloy stainless steel wire bonded only to the lingual surfaces of dogs.
While there have been several generations of fixed braces over the years, they all still come with the same baggage.
Problems related to fixed braces
Placing
Fitting fixed braces is not for the faint of heart. You have to fight against the patient’s tongue and soft tissues while maintaining excellent moisture control.
Visibility and access can also cause problems, especially when dealing with retroclined lower incisors. Fixed upper retainers should ideally be positioned to avoid occlusal interference.
Oral hygiene
Studies have shown that fixed braces often cause increased plaque and tartar build-up.
Failure
There are several types of associated bearing failure.
Bonding interface failure ranges from 3.5 to 53%, and is greater in the maxillary arch when compared to the mandibular.
Metal fatigue can occur with long-term wear of the retainer resulting in fracture along the length of the retainer without detaching from the tooth surface.
Most failures occur within the first two years after deployment.
distortions
Sudden torque movements can lead to tooth displacement or dehiscence.
design
The failure rate of fixed retainers attached to six lower front teeth is much lower at 9 to 14% than for those attached to lower canines alone, which is reported to be 13 to 37.7%.
So how do we address these issues to provide better outcomes for our patients?
settlement
Placing
Many find that using aids such as page pullers and lab-made tools help place the aid. Others use a combination of floss and orthodontic elastic to hold the retainer in place while the adhesive is placed.
Oral hygiene
Patients should be shown how to supplement their regular oral hygiene routine with small-diameter interdental brushes or Superfloss for interproximal cleaning. This reduces the build-up of plaque and, ultimately, stones in this region.
I often tell patients that excellent oral hygiene is a prerequisite for fixed braces.
Failure
Patients’ suitability for fixed braces should be carefully considered; the care they took with their braces/liners can be a useful indicator.
Instructions should be given to avoid biting hard foods with front teeth. Obviously, occlusal cleaning should be included in treatment plans where fixed upper retainers are considered necessary.
distortions
Make sure fixed braces are passive when fitted, give patients clear care instructions for the attached brace, and consider the best materials for each case.
My brace brace is Ortho-flextech which does not accept active bends.
design
If fixed retainers are required, aim for designs with the lowest failure rate by bonding to all teeth behind which the fixed retainer will be placed.
Are fixed retainers worth the effort?
Given the high failure rate and complexity of fitting and maintaining fixed braces, do I think it’s worth the effort?
In some cases, of course. I feel that patients with moderate diastemas, rotations, and severely displaced lower incisors benefit from fixed braces, and I still offer them in these scenarios.
But I carefully monitor my patients throughout their treatment regarding their suitability for fixed braces and they are informed at their initial consultation of certain criteria that must be met before they are fitted.
This provides complete clarity on the pros and cons of fixed braces, and the work required to maintain them. This allows patients to make an informed decision about whether a fixed brace is something they want to commit to.
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