What is the best treatment for children with crowded teeth?

When teeth erupt (come through the gum into the mouth), they may twist, stick out, drop back, or overlap if there is not enough space in the mouth. Losing baby teeth early from tooth decay or trauma can lead to crowded permanent teeth. If crowded teeth affect a child’s self‐esteem or cause pain, damage or chewing problems, the child may be referred to a specialist dentist known as an orthodontist to correct them. Crowded teeth can be prevented or corrected using braces if crowding is mild (less than 4 mm). Removal of some teeth (extraction) may also be needed if crowding is moderate (4 to 8 mm) or severe (more than 8 mm). Fixed braces are used on permanent teeth. Removable braces can be used on baby or permanent teeth, or both. Baby or permanent teeth can be extracted.

Interventions to encourage eruption of eye teeth buried under the gum or growing upwards, without the need for surgery, in children aged 9 to 14 years

Upper permanent canine teeth (commonly known as eye teeth or fang teeth) are positioned in the upper jaw, one on the right and one on the left. In around 1% to 3% of children, they may not erupt (appear from behind the gum and into the mouth) into their correct position. The permanent canine tooth or teeth may grow towards the palate (roof of the mouth) and remain unerupted (buried under the gum). This is known as a palatally displaced canine (PDC). If the permanent canine tooth remains displaced and unerupted, it can damage or change the position of neighbouring teeth, and occasionally it can lead to a cyst.

Management of a PDC can take a long time, involving surgery to uncover the tooth and prolonged orthodontic (brace) treatment to straighten it. Various quicker or easier alternatives have been suggested to encourage the tooth or teeth to erupt. These include extraction (taking out) of the primary (baby) canine, extraction of the primary canine and primary first molar (also called double primary tooth extraction), or using braces to create space in children’s mouths.

Are braces effective for treating crossbite (top back teeth biting down inside the bottom back teeth)?

Posterior crossbite occurs when the top teeth or jaw are narrower than the bottom teeth. It can happen on one side or both sides of the dental arches. This condition may increase the likelihood of dental problems (e.g. tooth wear), abnormal development of the jaws, joint problems, and unbalanced facial appearance. Posterior crossbites affect around 4% and 17% of children and adolescents in Europe and America. 

Different treatment approaches have been proposed, resulting in many different braces being produced. The basic treatment to correct crossbite correction treatment involves using an orthodontic device on the palate (roof of the mouth) to expand the upper jaw by exerting pressure on both sides of the jaw. The devices can be fixed (e.g. quad‐helix, Haas, Hyrax expander) or removable (e.g. expansion plate). Fixed appliances are bonded to the teeth, while removable devices can be taken out of the mouth by patients.

Fluorides for preventing early tooth decay during fixed brace treatment

Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build-up of dental plaque around the brackets that attach the fixed brace to the teeth. If the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth.

Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth?

Which material works best for the first arch wire in a fixed brace?

Orthodontic treatment is undertaken worldwide to correct crowded, twisted, buried or prominent front teeth. This treatment is normally given in adolescence or adulthood. Fixed orthodontic appliances, otherwise known as braces, consist of brackets bonded to the teeth. The brackets are connected by arch wires, which exert forces on the teeth to straighten them. The first, or initial, type of arch wire, inserted at the beginning of treatment, is for correcting crowded and twisted teeth. Over recent years, a number of new materials have been developed, which show a range of different properties in the laboratory and which manufacturers claim offer benefits in terms of tooth alignment. These include mixtures of nickel and titanium (NiTi).

Early-phase treatment of prominent upper front teeth in children may have benefits

Prominent (or sticking out) upper front teeth are a common problem in children around the world. For example, this condition affects about a quarter of 12-year-old children in the UK. The correction of this condition is one of the most common treatments performed by orthodontists (dentists who specialise in the growth, function and position of teeth and jaws). This condition develops when the child’s permanent teeth erupt. Children are often referred to an orthodontist, for treatment with dental braces, to reduce the prominence of the teeth. Prominent upper front teeth are more likely to be injured and their appearance can cause significant distress. If a child is referred at a young age, the orthodontist is faced with the dilemma of whether to treat the patient early or to wait until the child is older and provide treatment in adolescence.

In ‘early treatment’, treatment is given in two phases: first at an early age (seven to 11 years old) and again in adolescence (around 12 to 16 years old). In ‘late treatment’ (one phase), there is only one course of treatment in adolescence.

As well as the timing of treatment, this review also looked at the different types of braces used: removable, fixed, functional, or head-braces.

How effective are painkillers in reducing the discomfort caused by orthodontic treatment?

Pain is a common side effect of orthodontic treatment. The pain resulting from orthodontic treatment may differ depending on the amount of force applied and the type of braces used. It may also change over the first few days following treatment. Pain has been ranked as the worst aspect of treatment and is the most common reason for people wanting to discontinue orthodontic treatment. Painkillers, swallowed or applied directly to the sore areas of the mouth following treatment, are thought to relieve the pain, making brace treatment more comfortable and acceptable. These painkillers are often cheap, readily available, easy to use and do not cause serious side effects.

No RCT evidence to determine best technique for exposing displaced eye teeth

Permanent canine teeth in the upper jaw usually erupt into the mouth between the ages of 11 to 12 years. In 2% to 3% of young people, the canine teeth fail to erupt (grow down) and become displaced in the roof of the mouth (palate).This can leave unsightly gaps, cause damage to the surrounding roots (which can be so severe that neighbouring teeth are lost or have to be removed) and, occasionally, result in the development of cysts.

Management of this problem is both time consuming and expensive. It usually involves surgical exposure (uncovering), followed by fixed orthodontic braces for two to three years, to move the canine into the correct position. Two surgical techniques are routinely used in the UK: the closed technique involves uncovering the buried tooth, gluing an attachment onto the exposed tooth and repositioning the palatal flap. Shortly after surgery, an orthodontic brace is used to apply gentle forces to bring the canine into its correct position within the dental arch. The canine moves into position beneath the gum. An alternative method is the open technique, which involves surgically uncovering the canine tooth as before, but instead of placing an attachment onto the exposed tooth, a window of gum from around the tooth is removed and a dressing (pack) placed to cover the exposed area. Approximately 10 days later, this pack is removed and the canine is allowed to erupt naturally. Once the tooth has erupted sufficiently for an orthodontic attachment to be glued onto its surface, orthodontic braces are used to bring the tooth in line with the other teeth.

Lasers may help to reduce pain in orthodontic treatment: but more high quality research is needed

Pain is usual during orthodontic treatment, especially when a brace is placed on the teeth. Later adjustments of the brace can also result in pain, sometimes lasting up to a week or more. This can make people stop their orthodontic treatment, meaning that the benefits are lost. Painkillers have been recommended to reduce pain, but an effective non-drug solution would lower the risk of side effects and help people follow the full course of treatment.

Evidence inconclusive on giving painkillers to children before dental treatment

Dental pain is common after dental procedures and can lead to increased fear of dental treatment, avoidance of dental treatment and other associated problems. Reduction of pain is important, particularly in children and adolescents. One way of managing this might be to give painkillers before treatment so that the painkillers can start to work right away. This updated review looked at evidence for using painkillers in children, aged up to 17 years, undergoing treatment without sedation or general anaesthetic, but who may have had a local anaesthetic. The treatments included extracting teeth, restoring teeth and fitting braces.