Problems during treatment

Question 1

I had my braces fitted yesterday and a bracket came off today. Do they come off that easily?

Accepted Answer

Fitting braces is a lengthy procedure that requires each bracket to be precisely positioned on the tooth. Brackets have to be bonded to an absolutely clean surface, which is why the procedure often has to start with cleaning the teeth. Another factor that affects how firmly a bracket bonds is moisture. If the tooth gets wet before the bracket is placed, the adhesive may not set with its normal strength. Often, when the archwire is put in, such a bracket comes off while the patient is still in the chair. The orthodontist can then deal with it on the spot and bond it back on. At the end of the procedure, I always warn my patients that there is a chance one of the brackets hasn't bonded at full strength. If so, it will come off the first time you eat, even if the food is soft. This shouldn't worry you. Sometimes we simply didn't see that the tooth had become wet. If a bracket comes off very soon after being fitted, contact your orthodontist, who will arrange an appointment to bond it back on.

Question 2

I'm at the start of my treatment and several brackets have already come off. Whose fault is it?

Accepted Answer

Possible reasons for a bracket coming off are: a wet tooth surface when the bracket was fitted, eating or biting into hard food, contact between the upper teeth and the lower brackets when eating, and clenching the teeth. The most common reason for a bracket coming off at the start of treatment is a poor bond between the adhesive and the tooth when it was fitted. If this happens, of course, it is not the patient's fault. Sometimes, while we are getting used to the diet that braces require, we may eat foods that aren't very suitable for the appliance. This is a process of adapting to something new in the mouth. At first the patient is very anxious and eats only soft foods, mostly puréed. Over time they find that the braces are firmly in place and start allowing themselves slightly harder foods. Some patients allow themselves foods that are far too hard, until a bracket comes off. Then the patient works out what not to eat and how careful to be to avoid similar problems. Contact between the upper teeth and the lower brackets is more common with a deep bite. We usually prevent such contacts by placing materials in the mouth that stop the teeth from closing fully. If for some reason these materials don't block the contact well enough, the lower bracket comes off again through no fault of the patient. Once we correct the problem, this shouldn't happen again.

Question 3

If a bracket comes off, could it be because of weak glue?

Accepted Answer

Brace adhesive is a superbly engineered material, designed to give the strongest possible bond with the enamel while also allowing that bond to be broken without harming the tooth when the time comes to remove the braces. There is no such thing as weak brace adhesive – the reason a bracket can come off from hard food is that we do, after all, want to take the braces off all the teeth one day. Unfortunately, the solution to brackets coming off isn't a stronger adhesive, but limiting the foods that can put excessive pressure on the braces.

Question 4

The hooks on my side brackets are scratching me. Can they be cut off?

Accepted Answer

Some types of brackets come as standard with built-in hooks pointing towards the gum, which gives them a rectangular shape with one protruding corner. These hooks are used for attaching elastics, which may be needed at various stages of treatment. Even if your orthodontic plan doesn't initially include wearing elastics, they are an important auxiliary that can be added if needed. For this reason, hooks are built into many types of brackets, and the mouth has to get used to them, as they can't be removed. If they irritate your cheeks or lips, we recommend temporarily covering them with orthodontic wax to ease the discomfort.

Question 5

If one bracket comes off, do all my teeth stop moving?

Accepted Answer

If only one bracket comes off, movement stops only for the tooth it was on. All the other teeth that have brackets bonded and connected by the archwire keep moving. If the loose bracket isn't put back straight away, that tooth can quickly drift back towards its original position. It sounds worrying, but it isn't a big problem. Once we put the bracket back in place, the tooth moves back into line within a few days.

Question 6

Does a bracket coming off delay my treatment?

Accepted Answer

If a bracket comes off in the first few months of treatment, while so-called ‘soft’ archwires are being used, rebonding it usually doesn't affect how long the treatment takes. At more advanced stages, when a ‘stiff’ or finishing archwire is already in place, a bracket coming off may mean going back to an earlier archwire size so that the displaced tooth can be brought back into line. In some cases this can extend treatment by 2–3 months. So, on the whole, it is important to avoid brackets coming off, to prevent delays and extra corrections.

Question 7

The end of my archwire is giving me a sore. Can I fix it with wax?

Accepted Answer

Wax stays put very well on a bracket because it moulds to its shape, but the archwire is flexible, so if you put wax on it, it will often fall off. If a sore in your mouth is caused by the end of the archwire behind the last bracket, wax is a temporary solution until you can find time to see your orthodontist, who can trim the wire or cover its end with a material that stops it poking.

Question 8

I can't get to my orthodontist and the end of my archwire is poking me. Can I go to my general dentist instead?

Accepted Answer

The best option in this case is to contact your orthodontist. Your general dentist can, of course, cut the end of the archwire with a drill or cover it with a material that stops it poking. Your orthodontist can tell you which is the better solution.

Question 9

My archwire has bent between my last two teeth. What should I do?

Accepted Answer

The first few archwires are thinner and flexible. Because we chew hardest with our back teeth, that's where food presses on the archwire the most. The stretch of wire between the last two brackets is the longest, because these are the largest teeth in the mouth. The longer the stretch of wire between two brackets, the softer and more flexible it is, and the more easily food bends it. That's why you may sometimes notice that the archwire by the back teeth has bent towards the gum in a U shape. As I mentioned, these archwires are very flexible. If you press under the curve of the wire with your finger and wiggle it gently, it will straighten out.

Question 10

My archwire has come out of the last bracket. What should I do?

Accepted Answer

The archwire bending between the last two brackets is the first step before it comes out completely. If this happens, you'll see the wire sticking out slightly and moving when you eat and talk. It may injure the lining of your mouth. Wax doesn't stay on an archwire for long, so it isn't a good way to deal with the problem. If you have a small pair of tweezers, you can grip the end of the wire and guide it back into the opening of the last bracket. If you can't, you can of course book an extra appointment with your orthodontist.

Question 11

One of my brackets has come off. Is it an emergency?

Accepted Answer

If you're in the earlier stages of treatment and a bracket comes off, it isn't an emergency as long as it isn't causing you discomfort, scratching or poking, and it can wait until your next check-up. If you've had your braces for a while when the bracket comes off, it's probably best to have it rebonded sooner. Of course, your orthodontist will give you instructions when you get in touch.

Question 12

One of my aligner buttons (attachments) has come off. Is it urgent?

Accepted Answer

Fortunately, nothing that can go wrong with aligners is ever an emergency for the patient. You won't feel any discomfort if a single button comes off. It's a good idea to let your orthodontist know, so that it can be put right within a few days.

Question 13

My braces don't look as if they're in the centre of my teeth. Is that normal?

Accepted Answer

Positioning the brackets is the most important step in fitting braces. Not every bracket should be bonded in the centre of the tooth. Each type of brace has a position on the tooth recommended by the manufacturer, so that the bracket can carry out the movement it's designed for as fully as possible. Different bites can also call for differences in positioning – for example, with a deep bite the front brackets may be bonded closer to the biting edges of the incisors, whereas with an open bite it's the other way round – they sit closer to the gum on the same teeth.

Question 14

I've broken my aligner. What should I do?

Accepted Answer

Different orthodontists will probably give different advice in this situation. The best thing, of course, is to contact your orthodontist. If you had only been wearing the broken aligner for a short time, you may be able to go back to the previous aligner in the sequence and wear it for another week. After that you can move on to the next undamaged aligner in the sequence – that is, skip one. If the damaged aligner was near the end of its wear period, you can try putting in the next one. In that case, I usually advise the patient to wear the next aligner for longer. Having a new aligner made is also an option.

Question 15

I can't find the bracket that came off – I've probably swallowed it. Is that a problem?

Accepted Answer

A bracket is a small, relatively smooth object. Swallowing one isn't a problem. It's biologically inert, you can't feel it as you swallow, it doesn't get stuck in the digestive system and it passes out of the body without any trouble, without you even noticing. You don't need to seek medical help if you've swallowed a bracket.

Question 16

Can my mini-implant come loose, and is that dangerous?

Accepted Answer

Mini-implants are auxiliary devices used in orthodontic treatment, usually small in diameter and length. They are placed in the jaw under a little local anaesthetic at a specific spot, where they can be connected to the braces with an elastic or a wire to help with a particular tooth movement. The most unpleasant side effect a patient can expect from a mini-implant is that it loosens, becomes wobbly or, in rare cases, falls out. The discomfort caused by a loose mini-implant is mainly mild soreness of the gum and the need to screw the mini-implant back in. For the patient, this means an extra appointment and another local anaesthetic. Nothing else unpleasant should be expected in this case.

Question 17

A small piece of my archwire has broken off and I may have swallowed it. Do I need to see a doctor?

Accepted Answer

The orthodontic archwire is sometimes left slightly longer than the last bracket, and its end is bent over so that it doesn't irritate the lining of the mouth. Occasionally this end breaks off and can be swallowed. If this happens, don't worry. This little piece of wire is 4-5 mm long and will pass through the body without any problem. If a longer piece of archwire has broken off – for example, more than 15 mm – and you suspect you've swallowed it, it's usually still not a problem, but you may want to consult a doctor to be on the safe side.

Question 18

My orthodontist said they'll need to rebond a few brackets. Is that normal?

Accepted Answer

At the start of treatment the teeth are at their most out of line: some are badly rotated, others have gaps, and a tooth may be largely hidden behind another one. This makes it difficult, and sometimes impossible, to place the bracket perfectly in the middle of the crown. Once the levelling stage with braces is over and most of the teeth are in line, we assess the position of the brackets and, if necessary, rebond individual ones. This is a perfectly normal part of treatment and actually saves time, because repositioning a bracket is the quickest way to correct a tooth.

Question 19

I've run out of elastics. Can I buy some at the pharmacy?

Accepted Answer

Your orthodontist will normally give you enough packets of elastics to wear them as instructed. Still, elastics do sometimes get lost or spilt, or you may have forgotten to mention at your last appointment that you needed more. In these exceptional situations you need to contact your orthodontist to get more elastics. They are not sold in pharmacies or in shops that patients can easily get to. You may have noticed that the packets have an animal and some numbers printed on them – these correspond to the size and strength of the elastics. You can replace your elastics with another brand only if the numbers on the packet match.

Question 20

The coloured elastic tie has come off one of my brackets. Do I need to go in and have it put back?

Accepted Answer

A single elastic tie can come off a bracket – sometimes because of over-vigorous brushing, sometimes because the tie was worn. The problem doesn't need urgent attention. You can see your orthodontist within about a week; if that isn't possible, the tooth will probably shift slightly in an unwanted direction.

Question 21

A crown with a bracket on it has come loose. Who should I see – my orthodontist or my dentist?

Accepted Answer

In this situation the crown has often come unstuck and is loose in the mouth, but is still held on the archwire by the bracket. You may need to see both your orthodontist and your general dentist. The orthodontist needs to free the crown from the brace. They may also offer to cement it back in place if they have a suitable cement. This isn't always possible, as orthodontists don't usually fit crowns, so after the orthodontist you will need to go to a general dentist, and then finish the round back at the orthodontist's to have the archwire reconnected to the bracket.

Question 22

Can my orthodontist add a new bracket or button during treatment?

Accepted Answer

Rebonding brackets, or adding individual new brackets or buttons after treatment has started, is completely normal. It is usually planned by the orthodontist in advance, but sometimes it is decided at a later stage of treatment. These are auxiliaries for attaching elastics or achieving a particular tooth movement. There is no need to worry about changes like these.

Question 23

A piece of plastic or wire has broken off my removable appliance. Does it need fixing urgently?

Accepted Answer

If the appliance is broken, it needs to be repaired before treatment continues – a part that is important for moving the teeth may have broken off. So stop activating the appliance and contact your orthodontist. If you can't see your orthodontist straight away and the appliance doesn't sit properly in the mouth because of the break, at least try to sleep with it in until the problem can be sorted out.

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